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CITY,OF:SALEM BOARD OF-HEALTH
m
Sale ', Massachusetts 01970-3928
I JOANNE SCOTT,MPH,RS,CHO 120 Washington Street 4 Floor s,
+ HEALTH AGENT Tel.(978)741-1800',
iy
Faz 978 745 0393 t g
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4
d
WELL CONSTRUCTION'PERMIT
' ,##Location�z 37 Intervale Road M a{
h kV� • , gw q'rS +t '�fi4 by Ml• tt� 4 S "N L��` 6.. F t
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Owners Ed'Connor .
3�Villr, ,sA
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a s Address- } 37jiIn� „tervale Road e
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This permit is granted m.conformlty with the statutes and orginancesrrelating§to , � 2�<f
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d This permit shall be on site at all times that work is,taking placer Permit shall .�yy, , s,
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expire3one (1);year from the date,of issuance unl6sW,revoked from cause I s
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�►�wtAGENCY
v V REALTORS
300 Salem Street '*
Vinnin Square ""
Swampscott, MA 01907 "e r
u Maggie Ross Tobey g 24k
REALTOR®
Flwe: 7�/-(039- �/23
Voice Mail: 781-477-2541
Office: ,.78.'FW""1
Fax: '28 �'
CITY OF SALEM BOARD OF HEALTH
Salem, Massachusetts 01970-3928
JOANNE SCOTT,MPH,RS,CHO t'V - Hyl - I9ua
NINE NOR1-H STREET
HEALTH AGENT Tcl:(699)741-1800
p Fax:(%8))74/0-9705
Pcrmit9 �d � Date /t(G`
Ap�iicatiQlt.�y�r Welt find Putlltr p/rmit
Ape rmit is requested to: drill a well ✓ install a pump✓ other _
LOCATION: 3-7 Lot#
Owner 5E�? ("r),cA1&e- Address?7 -P&,7,EMV We X Tet. (-5"-
We]
-5ri�-
WeII Contractor je//i�U /Cj//a.u� Add./�3/nr9svJ �P��v�, Tel
Pump Contractor kt Add. y Tel. -2
----------------------------------------------------------------------------------------------------------------------
Wells (To be completed at time of pump test.)
Type of well Use
Well Diameter Size of casing ;
Depth to bedrock _.•_.-. . ...---•-_-.... ..Depth of casing into bedrock
Was it seal tested ? yes O no O Date of testing
Depth of well Well ended in what material ? _
Depth to water _ Delivers Gallons per minute.
Drawdown _ feet after putnping.- ... _ hours at Gallons per minute.
T(Please.sketch mop of well incation with tie down linea on reverse.side of this forrn.
Completion date: Well contractor signature: Reg!1_
-------------------------------------------------------------------------- -------------------------...----•---------
Pumps (To be completed before installation.
Name and sire of pump: ------- - Type
Water.pump delivers: _GPM. Sire of tank
Pipe material used in well: cast iron ( ) galvinized ( ) plastic ( )
Circle one : Well pit or Pitless adaptor.
Was sleeve used to protect pipe? yes ( ) no ( ). Well seal type: __..-. _ _._.._
Date: _ _-_ _._ Pwnp installer signature: _ Reg.tl _
--------------------------------------•-------...-------------------------------------------------=---------• -------
Plumbing Inspector Wiring Inspector Board of Health
CITY OF SALEM BOARD OF HEALTH
Salem, Massachusetts 01970-3928
JOANNE SCOTT,MPH,RS,CHO - NINE NORTH STREET
HEALTH AGENT Tet:(beg)741-1800
Fax:(W)740-9705
4
Permit N Date
A icatiQ�a..fQr)3'e1l and Purllp.�erru�
A permit is requested to: drill a well✓ install a pump✓ other
LOCATION:371'n�eZ✓qtE a� Lot# IY6 �
Own e Address i7r; Tel. / 3� ZZ
�. . ----
Well Contractor ✓ F :--Add.11 IrI4 u;Z� e Tel.M2
Pump Contractor----- Add. _Tel.
------------------------------------------------------------------------------ --------------------- -------
Wells (To be completed at time of pump test.)
Type of well Use—"
Well
se_—_._-,. , ,Well Diameter Size of casing
Depth to bedrock_-.--- -- . --.._.... .. Depth of casing into bedrock
Was it seal tested ? yes O no ( )• Date of testing
Depth of well Well ended in what material ? _
Depth to water Delivers Gallons per minute.
Drawdown _ feet after pumping-. „ _—_hours at Gallons per minute.
(Please,sketch man of well location with tie down lines on reverse side of this form.)
Completion date: Well contractor signature: Reg fl
Pumps (To be completed before installation.)
Name and size of pump: — --—-- - Type
Water pump delivers: —_____.__•._____.,__,,, _.GPM. Sire of tank
Pipe material used in well: cast iron O galvinized ( ) plastic( )
Circle one : Well pit or Pitless adaptor.
Was sleeve used to protect pipe? yes ( ) no ( ). Well seal type: _-.__
Date: _ _ -_ Pump installer signature: ._,__... Reg.#! _—
---------------------------------------------------------------- ---------------------------------------- -----------
Phtmbing Inspector Wiring Inspector Board of Health
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CITY OF SALEM BOARD OF HEALTH
Salem, Massachusetts 01970-3928
JOANNE SCOTT, MPH, RS,CHO ton Street 4th floor 120 Washington HEALTH AGENT g
Tel: (978-741-1800)
Fax: (978) 745-0343)
WATER QUALITY TESTING REQUIREMENTS
-AFTER THE WELL HAS BEEN COMPLETED AND DISINFECTED,AND PRIOR TO USING IT AS
A DRINKING WATER SUPPLY, A WATER QUALITY TEST SHALL BE CONDUCTED.
A WATER SAMPLE SHALL BE COLLECTED EITHER AFTER PURGING THREE WELL
VOLUMES OR FOLLOWING THE STABILIZATION OF THE PH,TEMPERATURE AND SPECIFIC
CONDUCTANCE IN THE PUMPED WELL. THE WATER SAMPLE TO BE TESTED SHALL BE
COLLECTED AT THE PUMP DISCHARGE OR FROM A DISINFECTED TAP IN THE PUMP
DISCHARGE LINE. IN NO EVENT SHALL A WATER TREATMENT DEVICE BE INSTALLED
PRIOR TO SAMPLING.
THE WATER QUALITY TEST, UTILIZING EPA METHODS FOR DRINKING WATER TESTING
(500 SERIES METHODS) AND NOT METHODS USED FOR ANALYZING WASTEWATER,
SHALL BE CONDUCTED BY A CERTIFIED LABORATORY AND SHALL INCLUDE ANALYSIS
FOR THE FOLLOWING PARAMETERS:
Parameter Maximum Contaminant Level (MCL)
*Coliform Bacteria Positive sample
Parameter Recommended Upper Limit Lower Limit
Alkalinity 100 mg/I 30 mg/I
Calcium 150 mg/I 50 mg/I
Chloride 250 mg/I n/a
Color 15 color units n/a
Copper 1 mg/I n/a
Hardness 200 mg/I 50 mg/I
Iron .3 mg/I n/a
Magnesium relative scale
Manganese .05 mg/I n/a
Odor 3 TON n/a
pH 8.5 6.5
Potassium relative scale
Sediment visual Observation
Sulfate 250 mg/I n/a
Total Dissolved Solids 500 mg/I n/a
CITY OF SALEM HEALTH DEPARTMENT
$ a
Salem, Massachusetts 01970
Volatile Organic Compounds
Parameter Maximum Contaminant Level (MCL)
Benzene .005 mg/I
Carbon tetrachloride .005 mg/I
Dichloromethane .005 mg/I
o-Dichlorobenzene .6 mg/I
p-Dichlorobenzene .005 mg/I
1,2-Dichloroethane .005 mg/I
cis-1,2-Dichloroethene .07 mg/I
trans-1,2-Dichloroethene .1 mg/I
1,1-Dichloroethene .007 mg/I
1,2-Dichloropropane .005 mg/I
Ethylbenzene .7 mg/I
Chlorobenzene .1 mg/I
Styrene .1 mg/I
Tetrachloroethene .005 mg/I
Toluene 1 mg/I
Trichloroethene .005 mg/I
1,1,1-Trichloroethane .2 mg/I
1,2,4-Trichlorobenzene .07 mg/I
1,1,2-Trichloroethane .005 mg/I
Vinyl Chloride .002 mg/I
Xylenes (total) 10 mg/I
Inorganic compounds
Parameter Maximum Contaminant Level (MCL)
Antimony .006 mg/I
Arsenic .05 mg/I
Asbestos 7 million fibers/I
Barium 2 mg/I
Beryllium .004 mg/I
Cadmium .005 mg/I
Chromium (total) .1 mg/I
Cyanide .2 mg/I
Fluoride 4 mg/I
Lead (action level) .015 mg/I
Copper(action level) 1.3 mg/I
Mercury .002 mg/I
*Nitrate(N) 10 mg/I
*Nitrite (N) 1 mg/I
Total Nitrate & Nitrite (N) 10 mg/I
Selenium .05 mg/I
Thallium .002 mg/I
'indicates parameters that should be monitored once every year.
The most recent certified lab list can be obtained by calling the Wall Experiment Station at(978)682-5237
or by accessing the information at http://www.state.ina.us/dep/bspt/wes/wespubs.htni
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'* CITY`OF SALEM, MASSACHUSETTS , •°
rr 2 ra
;B'OARO bF;,HEALTH4 :k
3 � 120 WASHINGTON STREET;4TH',FLOOR'gr':a
- s SALEM, MA OI 970
^� TEL. 978-741-1800 Y..
FAX 978-745-0343. 5��:�'i 5`,-.� '•
STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT '
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'° �• Z^F�$`" .{"i�aoC�Y- .' T 0.i- .�yt�j Y t7 �.. is �l'e
Commonwealth of Massachusetts .
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>r City of'Salem ,
WELL°WATER SUPPLY-CERTIFICATE3' .
Location. 37•intervale,Road.'
Owner Edward & Patricia Connor ; a k
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IV!V -444.-y
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Address 47 Herschel�Street;Lynn
,, §-s:
This certificate is granted'in conformity with the statutes and;or dinaznces relating
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99 Certificate #
Date issued :aj t>` 02%13 t/02
Health Agent a
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9��IMfNE
CITY OF SALEM BOARD OF HEALTH
Salem, Massachusetts 01970
120 Washington Street 4h floor
JOANNE SCOTT, MPH, RS, CHO Tel: (978)741-1800
HEALTH AGENT Fax: (978)745 0343
Well Water Supply Certificate Application
The issuance of a Water Supply Certificate by the Board of Health shall
certify that the private well may be used as a drinking water supply. A Water
Supply Certificate must be issued for the use of a private well prior to the
issuance of an occupancy permit for an existing structure or prior to the issuanra;
of a building permit for new construction which is to be served by the well.
The following must be submitted to the Board of Health to obtain a Water Supply
Certificate :
"copy of the Well Construction Permit
VP,t,IggL 'copy of the Water Well Completion Report as required by the DEM
Office of Water Resources (313 CMR 3.00)
VtJzve.*copy of the Pumping Test Report
'copy of the Water Quality Report
----------------------------- --s-----�---,-----f--,-,--'----------------------------------------------------------
Location of well: 3 �/ 1)aya Q l— Pd . Salem, MA.
Owner of property: FjI .t Pak(-O- (�Y I/n--Tel. -l&(-561.C1-5 6 W
Owner's address: Ti PISGB, o — �It !/1/A
Date:
------------------------------------------------------------------------------------------------------------
B.O.H. use only Permit # N-v I
9 �
�i NN o/L.
I
0037 INTERVALE ROAD 260-2001
GIs#: sass COMMONWEALTH OF MASSACHUSETTS
Map: 121 CITY OF SALEM
Block:
Lot: 0068 i
Permit: Building
Category: 101 New single fame BUILDING PERMIT
Permit# 260-2001
roject# 7S-2002-0500
Est.Cost: $100,000.00
Fee: $605.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class- Contractor: License:
IUse Group: HOMEOWNER
`otSize(sq. ft.): 7973 Owner: BLACKLER THOMAS P
',zoning: Ri Applicant: Edward&Patricia Connor
Units Gained: AT: 0037 INTERVALE ROAD
Units Lost:
ISSUED ON. 04-Oct-2001 EXPIRES ON. 04-Apr-2002
TO PERFORM THE FOLLOWING WORK.
Construct new single family dwelling per plans submitted. P.S.
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plu in Inspector of Wiring D.P.W. Inspector of Buildings
Footings:
Underground: y7 Service: Meter:
Foundation:
ough: /p Rough: /� yl�Jf• House#
Rough Frame:
Final: /7 Final: Fireplace/Chinmey:
Insulation:
Fire Department Board of Health Final:
/ -.z t
Rough: OIL Treasury:
Ateail/� �F a l3-0�
Final: Smoke: Well wader Excavation:
THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON:V1;;0V1, 4V
ITS RULES AND REGULATIONS.
Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
BUILDING REC-2002-000541 04-Oct-01 01 $605.00
Call for Permit to Occupy
GeoTMS®2001 Des Lauriers Municipal Solutions,Inc.
4
02/12/02 TUE 16:10 FAX 5089225895 BEVERLY HEALTH DEPT 002
Pc GE 01
10/Cd/e001 09:58
9706920073 1HOR9TFNSEN LAS
J/iatsfen:►en +atafa2i �wc•
66 LITTLETON ROAU.VVES7fOno MA 01600 (9781082.8395 FAX(978)692 002] 1-B0aGa8 TEST
Repos Numbe 59745, �r(� Ripon Date 10)v0 t Zo
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Sample Idermaria
Cl,car I OIL
A•e111aa Well&Puma
:,y erapQj{ y)Wrnalel�d
la3Main x i• �C .rc
Reading MA 01867 T SoieE
Sampled by'. C6en1 o.,c A=cd�ed: 10arOt r'ale Sampled: 1012,01
Ceti tcdte of Analysis
( t� y t ray EPA Lomt _8.eouMa Units
1 ��d 2 Pcr100m1
f✓Q Tod Coliform(P) 0
✓ Fecal Cohfomv Exerb(P) Absent 1 �Kb` pvt00m1
6'' V Calcium No Limit 611 mg/L
40.02 mctL
Capps(S) 1.1
Or Iran(S) 0.3 0.26 n`g/L
✓ Magnnium No Limit 21.5 mg(.
a/ Mangnneac(S) 0,05 0 0.04 mflL
✓Potassium No Until 50 MCIL
Sodium Seo Note 284 mgrL
a f Alkali ay(S) NO Limit 96.5 �2
r/ Ammonia-N No Limit 007 mg/L
✓ OJouda(S) 250 1'2.5 EMIL
Chlorine No Limit 40.02 rq/L
be Color(S) 15 5 CPU
ConducHairy Ne Lunit 640 ambodcm
Q Hardnca p-)IM NoLtmit 2!3 myL
0 4041
/ N,eate-N(P) 1 <0.01 mgrL J
✓Ni0 re.N(P) 1
beOdor ) 1 TON
✓PH(S) 6,59.5 77 SU
✓ Sulphate(S) 250 ?6.2 mg/L
Tutbtdtry Not Spec. 0.85 NTU
✓Sediment foarneg Reg V
(P)-Primary EPA StaA01d.(S)-Sec0adary EPA Swndard.wE.xeda EPA Lunn.
TNTC-Too Numemua TO COdm. Buekgrowd 9ettena Head,'=E:coeds Ad°n°q'L^0 \J
5odwn Ad�taory Lroute M-06-=20,Q2H 250. •r, ......
� �'�t49rLuu7:EPA'�maderd>>V
'`..nJvytg�"'giaR3` ua con5lyi cYt'1171F'h''I6sumaA eoVoPaltm •\
Massachusetu:ettifcanon d MA042 Michael P.Carlson,for
New Hampsh.re CeRificaron a 2739 Thoratamce,Laboratory lac. 1
0CT 04 '01 16'27- �RGE.01
' Massachusetts Department of Environmental Management C c n
Office of Watef Resources O`�6 L Q
TYPE OR PRINT ONLY 4 Well Completion Report
1:'.WELLLOCATION.R I GPS (OPitIONAI ":« PLATITUDE- 2aw; LONGITUDE iµ
Address at Well Location: Property Owner:
Subdivision Name. " Mailing Address: 1kri4elill . M, of go,-
City/Town: 9 40�V City/Town:
n .
Assessors Map LAssessors Lot#: 08 NOTE: Assessors Map and Lot# mandatory if no street addre s avajlable
Board of Health permit obtained: Yes Not Required ❑ Permit Number 3`V'� Date Issued' �a G
2. WORK PERFORMED ", 3 PROPOSED USE!:" a A?DRILLINGMETHODA_„=e
New Well ❑ Abandon Domestic ..Irrigation Cable yn ❑yAuger
Deepen El Recondition EJ Monitoring ❑ Municipal Air Hammer`y,O Direct Push
❑ Replace El Other El Industrial ❑ Other El Mud'Rota "3,❑ Other
5':WELL°LOGm Unconsolidated Consoliclatedl 6'SITE SKETCH (Userermarmanentta`namarkswitn"aisrancesj„
PermeabilAy
n N a 9
From (ft) To (ft) 3: High Low V ur " c� m Other Rock Type -
,y ,
l 1 --
}
Are-
7.'WELL CONSTRUCTION T S
Total Depth Drilled 1 1 From (ft) To (ft) Casing Type and Material Size O.D. (in) Well Seal Type
Date Drilling Complete 8' 1Q
9 SCREEN
From (ft) Slot Size Screen Type and Material Screen Diameter
10. FILTER PACK/GROUT;/ABANDONMENT;MATERIAL; 4 , x;gr g
11 'ADDITIONAL WE LINFORMATKIN-
11 Developed? Yes ❑ No
From (ft) To (ft) Material Description T Purpose Fracture
Enhancement? ❑ Yes ❑ No
Method
Disinfected? Yes ❑ No
19w:ELLrTEST;DATA`(PRODUCTION WELLS) -e, f 1` _`._t&m . "`? 13 STATIC WATER LEVE -(ALLWELLS);;
Yield "NTime Pumped Drawdown to Time Recovery to Depth Below
Date Method (GPM) (hrs"A min) (Ft. BGS) (hrs & min) (Ft. BGS) Date Measured Ground Surface (FT)
` ✓! 20
ERMANENT:PUMP(IF AVAILABLE) .a t-• «ug, es 15. ANY;
1
Pump Description 2 1 Horsepower 143main St. 1
a :/ter r #'
Pump Intake Depth � r�', , (ft) Nominal Pump Capacity (gpm)
16.COMMENTS
17. WELL DRILLER'S STATEMENT, "`"_ This well was drilled and/or abandoned under my supervision, according to applicable rules
and regulations, and fhiyeport is complete and correct to the best of my knowledge.
Driller ���t�0_ Supe ising Driller Signapk:/f� a iyL' h�".«- Registration #: I
` , �/
Firm: 3-14
e: � / /%/r' — Rig Permit#: /
NOTE. Well Completion Reports must be filed by the regtste ed well driller within 30 days of well completion.
BOARD OF HEALTH COPY /
i
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DEC 9 7 ?^r
GIiYCFSALEM
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CITY OF SALEM BOARD OF HEALTH
Salem, Massachusetts 01970-3928
JOANNE SCOTT,MPH,HS,CHO 120 Washington Street 4'"Floor
HEALTH AGENT _ Tel:(978)741-1800. .
Fax: 978-745-0343
WELL CONSTRUCTION,PERMIT
Location 37.Intervale Road
Owner Ed Connor
Address 37 Intervale Road
y i 9�1 l3 fe
u iYr2nt '�. -A-VI ' r i " 5] i ` » Ea�• r�3�v
his ermit isrgranted In conformity with the statutes and ordinances relating
. E
Cfi 1 ���, t �1..��i jY.r �° xP.•S/' 2Y S �rs�rY' �i�;`� c �<g�``xx �' �{ S (�
Y sY Well nstruction permitslarenot,7,transferable ,
-2�',tr7-}9y�'��`r *�•3 ,di",b y x.lx
} x� F isermlt shall be on site at all times that work is taking place w Permit shall,b
=te KEfEt$fi� .A . . �° 4 g
fk�-,--- e plre;one (t ear fromthe date of Issuahce unless revoked from cause
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